Background noise lowers the performance of anaesthesiology residents' clinical reasoning when measured by script concordance: A randomised crossover volunteer study

How Many Is Too Many? Using Cognitive Load Theory to Determine the Maximum Safe Number of Inpatient Consultations for Trainees

PURPOSE

Cognitive load, specifically extraneous load (EL) reflective of distractions, may provide evidence of a lack of focus, potentially making additional work unsafe. The assessment of trainees performing inpatient consultations provides a helpful model for examining this question. The goal of this study was to provide useful information to clinical and educational leaders to optimize inpatient consultation services and rotations and mitigate potential patient safety risk.

METHOD

In 2019, using the Consult Cognitive Load instrument, the authors obtained EL data from inpatient consultations performed by internal medicine fellows and psychiatry residents across 5 University of California hospitals. In 2023, the authors constructed a Wright map to compare the participants' EL data with the number of prior initial consultations performed during the shift.

RESULTS

Of 326 trainees contacted, 139 (43%) completed the EL survey items. The Wright map shows that trainees were estimated to agree that interruptions were already distracting at the first consultation of the shift. After 4 consultations, trainees were estimated to strongly agree that interruptions were distracting, and to agree that emotions, extraneous information, and technology were distracting.

CONCLUSIONS

The authors propose a quantitative, empirically driven, mean safety limit of 4 new inpatient consultations per shift for trainees to avoid cognitive overload, thereby potentially supporting patient safety. Clinical and educational leaders can adjust this limit to fit the unique needs of their practice setting. A similar approach using cognitive load and item response theory could be used to conduct patient safety research in other domains.

Examining the impact of sleep deprivation on medical reasoning's performance among anaesthesiology residents and doctors: a prospective study

BACKGROUND

Working long consecutive hours' is common for anaesthesia and critical care physicians. It is associated with impaired medical reasoning's performance of anaesthesiology and serious medical errors. However, no study has yet investigated the impact of working long consecutive hours' on medical reasoning.

OBJECTIVE

The present study evaluated the impact of working long consecutive hours' on the medical reasoning's performance of anaesthesiology and intensive care physicians (residents and seniors).

METHODS

This multicentric, prospective, cross-over study was conducted in 5 public hospitals of Normandy region. Two groups of anaesthesia and critical care physicians were formed. One was in a rest group, RG (after a 48-hours weekend without hospital work) and the other in Sleep Deprivation Group (SDG) after a 24 h-consecutives-shift. Changes in medical reasoning's performance were measured by 69-items script concordance tests (SCT) through to the two tests. Group A completed the first part of the assessment (Set A) after a weekend without work and the second part (Set B) after a 24 h-shift; group B did the same in reverse order. The primary outcome was medical reasoning's performance as measured by SCT in RG and SDG. The secondary outcomes included association between the performance with the demographic data, variation of the KSS (Karolinska sleepiness scale) daytime alertness score, the number of 24 h-shift during the previous 30 days, the vacations during the previous 30 days, the presence of more or less than 4 h consecutives hours slept, the management of a stressful event during the shift, the different resident years, the place where the shift took place (University hospital or general hospitals) and the type of shift (anaesthesia or intensive care).

RESULTS

84 physicians (26 physicians and 58 residents) were included. RG exhibited significantly higher performance scores than SDG (68 ± 8 vs. 65 ± 9, respectively; p = 0.008). We found a negative correlation between the number of 24 h-shifts performed during the previous month and the variation of medical reasoning's performance and no significant variation between professionals who slept 4 h or less and those who slept more than 4 h consecutively during the shift (-4 ± 11 vs. -2 ± 11; p = 0.42).

CONCLUSION

Our study suggests that medical reasoning' performance of anaesthesiologists, measured by the SCT, is reduced after 24 h-shift than after rest period. Working long consecutive hours' and many shifts should be avoided to prevent the occurrence of medical errors.

Refocusing on work-based hazards for the anaesthesiologist in a post-pandemic era

The coronavirus pandemic has raised public awareness of one of the many hazards that healthcare workers face daily: exposure to harmful pathogens. The anaesthesia workplace encompasses the operating room, interventional radiology suite, and other sites that contain many other potential occupational and environmental hazards. This review article highlights the work-based hazards that anaesthesiologists and other clinicians may encounter in the anaesthesia workplace: ergonomic design, physical, chemical, fire, biological, or psychological hazards. As the anaesthesia work environment enters a post-COVID-19 pandemic phase, anaesthesiologists will do well to review and consider these hazards. The current review includes proposed solutions to some hazards and identifies opportunities for future research.

Guidelines on human factors in critical situations 2023

OBJECTIVE

To provide guidelines to define the place of human factors in the management of critical situations in anaesthesia and critical care.

DESIGN

A committee of nineteen experts from the SFAR and GFHS learned societies was set up. A policy of declaration of links of interest was applied and respected throughout the guideline-producing process. Likewise, the committee did not benefit from any funding from a company marketing a health product (drug or medical device). The committee followed the GRADE® method (Grading of Recommendations Assessment, Development and Evaluation) to assess the quality of the evidence on which the recommendations were based.

METHODS

We aimed to formulate recommendations according to the GRADE® methodology for four different fields: 1/ communication, 2/ organisation, 3/ working environment and 4/ training. Each question was formulated according to the PICO format (Patients, Intervention, Comparison, Outcome). The literature review and recommendations were formulated according to the GRADE® methodology.

RESULTS

The experts' synthesis work and application of the GRADE® method resulted in 21 recommendations. Since the GRADE® method could not be applied in its entirety to all the questions, the guidelines used the SFAR "Recommendations for Professional Practice" A means of secured communication (RPP) format and the recommendations were formulated as expert opinions.

CONCLUSION

Based on strong agreement between experts, we were able to produce 21 recommendations to guide human factors in critical situations.

Application of human factors at hybrid meetings: facilitating productivity and inclusivity

The COVID-19 pandemic has resulted in the widespread use of virtual meetings and conferences. As the healthcare sector attempts to return to normality, face-to-face meetings have started to resume. However, ongoing travel restrictions, risk of viral transmission, the Omicron variant, and requirements for self-isolation, have necessitated the use of novel hybrid meeting formats. These enable participants to attend either in person or virtually using various online platforms such as Microsoft Teams and Zoom. Well organised and facilitated hybrid meetings can combine the advantages of in-person meetings with virtual participation, although the dynamics of communication between attendees is considerably different. This article discusses the benefits and pitfalls of the hybrid format, the human factors that impact productivity and inclusivity, and how to address them in future meetings.

Effects of background noise and extraversion on reading comprehension performance

This study was concerned with the effects of acoustic distraction at work. Using a within-subject study we aimed to investigate the effect of background distraction on cognitive performance. In the presence of silence, white noise, and sirens, 55 fluent English speakers completed three equivalent variations of a reading comprehension task. As predicted, there was a significant main effect of background sound, with poorer performance in the presence of distraction (particularly sirens), but no interaction was found between distraction and extraversion. Thus, the findings partially replicated previous research in terms of distraction but were inconsistent with regard to the Eysenckian theory of arousal differences between introverts and extraverts. Implications of the effect of sirens on those they are not designed to alert are considered. Limitations of this study are also considered. Practitioner Summary: This study was concerned with whether white noise and the sound of sirens affects reading comprehension. We found that compared to doing a highly involving and demanding cognitive task in silence, siren noise has the most significant negative effect on performance. Compared to working silence, white noise also reduced the efficiency of text comprehension. There were no introvert-extravert effects.

The Perception and Attitude Toward Noise and Music in the Operating Room: A Systematic Review

BACKGROUND

Environmental noise pollution is regarded as a general stressor. Noise levels frequently exceed recommended noise levels by the World Health Organization in hospitals, especially in the operation room. The aim of this systematic review was to assess the effects of noise pollution on patient outcome and performance by operation room staff. In addition, the perception and attitude toward playing music in the operation room, which can increase noise levels, were assessed as well.

MATERIALS AND METHODS

A systematic literature search of the databases Embase, Medline Ovid, and Cochrane from date of database inception until October 16^th, 2020 using the exhaustive literature search method was performed. Prospective studies evaluating the effect of noise on the patient, surgeons, anesthesiologists, nurses, and other operation room staff, or perception and attitude toward playing music in the operation room, were included. This systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines and was registered with PROSPERO (ID: 208282).

RESULTS

The literature search generated 4758 articles, and 22 prospective studies (3507 participants) were included. Three of the four studies that investigated the effect of noise on patient outcome reported a significant reduction of complication rate in surgical patients, when noise levels were lower. Six studies assessed the effect of noise in the operation room on the staff (1383 participants). Over half of the surveyed staff found noise levels to be a disturbing stressor and negatively impact performance. Although music increased decibel levels in the operation room, most surveyed staff was positively predisposed toward playing music during surgery, believing it to improve both individual and team performance. In general, music was not considered to be distracting or impairing communication.

CONCLUSIONS

Higher noise levels seem to have a negative effect on patient outcome and adversely affect performance by members in the operation room. Further research is needed to assess whether this knowledge can benefit patient outcome and surgical performance. Notably, attitude of surgical team members toward music during surgery is generally regarded favorable.

Are script concordance tests suitable for the assessment of undergraduate students? A multicenter comparative study

INTRODUCTION

Script concordance tests (SCTs) have been developed to assess clinical reasoning in uncertain situations. Their reliability for the evaluation of undergraduate medical students has not been evaluated.

METHODS

Twenty internal medicine SCT cases were implemented in undergraduate students of two programs. The results obtained on the SCTs were compared to those obtained by the same students on clinical-based classical multiple-choice questions (MCQs).

RESULTS

A total of 551/883 students (62%) answered the SCTs. The mean aggregate score (based on a total 20 points) was 11.54 (3.29). The success rate and mean score for each question did not differ depending on the modal response but the discrimination rate did. The results obtained by the students on the SCT test correlated with their scores on the MCQ tests. Among students, 446/517 (86%) considered the SCTs to be more difficult than classical MCQs, although the mean score did not differ between the SCT and MCQ tests.

CONCLUSION

The use of SCTs is a feasible option for the evaluation of undergraduate students. The SCT scores correlated with those obtained on classical MCQ tests.

The Effect of Noise Levels in the Operating Room on the Stress Levels and Workload of the Operating Room Team

PURPOSE

The research was conducted to evaluate the noise levels and the effect of noise on the workload and stress levels of the operating room (OR) staff of a public hospital.

DESIGN

Descriptive and cross-sectional study.

METHODS

The data were obtained by measuring ambient noise during 403 orthopaedic, urological, and general surgeries on weekdays between July and October 2019. We measured the noise by dividing the surgery into three phases. These phases are as follows: from the entry of the patient, induction of anesthesia, and preparation of the surgical area until the start of the procedure (Phase I), from the incision until the completion of closure and dressing application (Phase II), from the completion of closure and dressing application until the exit of the patient (Phase III). Furthermore, the workload and stress levels of 45 OR staff who work in the general surgery, orthopaedics, and urology ORs were measured. Data were collected using a CA 834 noise measurement device, State-Trait Anxiety Inventory (STAI Form TX-I), the National Aeronautics and Space Administration (NASA) Task Load Index Workload Scale, and Information form related to surgery and ORs.

FINDINGS

The noise in the OR was higher than 35 dB, A-weighted [dB(A)], the limit proposed by the World Health Organization for hospitals. Phase I average noise level was 63.00 ± 3.50, Phase II average noise level was 62.94 ± 3.75, and Phase III average noise level was 63.67 ± 2.81. The mean anxiety score was 34.50 ± 6.09. The total workload level was found to be 56.91 ± 15.67. Anxiety scores and workload scores had positive weak and moderate correlations with noise levels (P < .01).

CONCLUSIONS

The noise in the OR was high, and anxiety scores and workload scores correlated positively with noise levels.

Virtual ARCP assessment and trainee feedback meetings: facilitating the best experience and practice

As a result of COVID-19, there has been an exponential increase in the use of remote technology for many local, regional and national meetings that would previously have been held on a face-to-face basis. Remote meetings have ensured that essential clinical, educational and strategic work can continue but it is not ‘business as usual’, although colleagues accept this form of communication as the new norm.

In medical education and assessment, the Annual Review of Competence Progression (ARCP) meetings and other formative educational meetings are being conducted remotely. This form of communication has some advantages but may also present possible barriers for feedback and development particularly for ‘trainees in difficulty’ when there are concerns about progression, and when an unsatisfactory outcome has been awarded. It is also worth remembering that there may be generational differences with the ease of use of virtual meeting platforms.

We present some of the important factors for optimising the panel of virtual ARCPs and discuss methods to improve feedback given remotely for trainees.

The effect of preferred music on mental workload and laparoscopic surgical performance in a simulated setting (OPTIMISE): a randomized controlled crossover study

BACKGROUND

Worldwide, music is commonly played in the operation room. The effect of music on surgical performance reportedly has varying results, while its effect on mental workload and key surgical stressor domains has only sparingly been investigated. Therefore, the aim is to assess the effect of recorded preferred music versus operating room noise on laparoscopic task performance and mental workload in a simulated setting.

METHODS

A four-sequence, four-period, two-treatment, randomized controlled crossover study design was used. Medical students, novices to laparoscopy, were eligible for inclusion. Participants were randomly allocated to one of four sequences, which decided the exposure order to music and operation room noise during the four periods. Laparoscopic task performance was assessed through motion analysis with a laparoscopic box simulator. Each period consisted of ten alternating peg transfer tasks. To account for the learning curve, a preparation phase was employed. Mental workload was assessed using the Surgery Task Load Index. This study was registered with the Netherlands Trial Register (NL7961).

RESULTS

From October 29, 2019 until March 12, 2020, 107 participants completed the study, with 97 included for analyzation. Laparoscopic task performance increased significantly during the preparation phase. No significant beneficial effect of music versus operating room noise was observed on time to task completion, path length, speed, or motion smoothness. Music significantly decreased mental workload, reflected by a lower score of the total weighted Surgery Task Load Index in all but one of the six workload dimensions.

CONCLUSION

Music significantly reduced mental workload overall and of several previously identified key surgical stressor domains, and its use in the operating room is reportedly viewed favorably. Music did not significantly improve laparoscopic task performance of novice laparoscopists in a simulated setting. Although varying results have been reported previously, it seems that surgical experience and task demand are more determinative.

Anesthesia assessment in the era of competences: state of the art

Introduction: Anesthesiology requires procedure fulfillment, problem, and real-time crisis resolution, problem, and complications forecast, among others; therefore, the evaluation of its learning should center around how students achieve competence rather than solely focusing on knowledge acquisition. Literature  shows that despite the existence of numerous evaluation strategies, these are still underrated in most cases due to unawareness. Objective: The present article aims to explain the process of competency-based anesthesiology assessment, in addition to suggesting a brief description of the learning domains evaluated, theories of knowledge, instruments, and assessment systems in the area; and finally, to show some of the most relevant results regarding assessment systems in Colombia. Methodology: The results obtained in “Characteristics of the evaluation systems used by anesthesiology residency programs stakeholders in the educational process, a fact that motivated the publishing of this discussion around the topic of competency-based assessment in anesthesiology. Following a bibliography search with the keywords through PubMed, OVID, ERIC, DIALNET, and REDALYC, 110 articles were reviewed and 75 were established as relevant for the research’s theoretical  framework. Results and conclusion: Anesthesiology assessment should be conceived from the competency’s multidimensionality; it must be longitudinal and focused on the learning objectives.

Human factors recognition at virtual meetings and video conferencing: how to get the best performance from yourself and others

During the current coronavirus pandemic, social distancing and restrictions on travel have resulted in a dramatic rise in the use of technology (including video conferencing) for remote meetings. From local multidisciplinary team (MDT) meetings to national and international committees, this form of communication has been vital to ensure patient-related and other business can continue, albeit in a sometimes unfamiliar environment. In this article we consider some of the human factors elements of remote meetings and provide suggestions to enhance the experience of team and committee members during this unsettling time. It is possible that this form of communication will continue to flourish after the pandemic is over.

Human factors awareness and recognition during multidisciplinary team meetings

Multidisciplinary team (MDT) meetings are widely used throughout medicine and dentistry, bringing together expertise and different opinions across many disciplines to benefit patient care. Depending on the cancer site and specialties involved, some MDTs can last for several hours, especially if there are many complex patients to discuss. However, concentration and attention can vary and distraction is almost inevitable with separate conversations between MDT members and the ever-increasing use of smartphones. The role of human factors (HF) in contributing to error is well known in high-risk activities including medicine and surgery. Surprisingly, while there is increasing awareness of their importance by medical and dental professionals to enhance patient safety, to our knowledge nothing to date has been published about the possible effect and role of HF at MDTs. Here we provide a brief HF overview and focus on the factors at an MDT that could lead to distraction, providing suggestions (including some from aviation) for possible ways to enhance and improve discussion during these often-long meetings. It is hoped that this paper will generate some thought and discussion around the current "normal" MDT practice in head and neck and other specialties and challenge colleagues to embrace HF and safety principles in a just and learning culture.

Use of the Smartphone App WhatsApp as an E-Learning Method for Medical Residents: Multicenter Controlled Randomized Trial

BACKGROUND

The WhatsApp smartphone app is the most widely used instant messaging app in the world. Recent studies reported the use of WhatsApp for educational purposes, but there is no prospective study comparing WhatsApp's pedagogical effectiveness to that of any other teaching modality.

OBJECTIVE

The main objective of this study was to measure the impact of a learning program via WhatsApp on clinical reasoning in medical residents.

METHODS

This prospective, randomized, multicenter study was conducted among first- and second-year anesthesiology residents (offline recruitment) from four university hospitals in France. Residents were randomized in two groups of online teaching (WhatsApp and control). The WhatsApp group benefited from daily delivery of teaching documents on the WhatsApp app and a weekly clinical case supervised by a senior physician. In the control group, residents had access to the same documents via a traditional computer electronic learning (e-learning) platform. Medical reasoning was self-assessed online by a script concordance test (SCT; primary parameter), and medical knowledge was assessed using multiple-choice questions (MCQs). The residents also completed an online satisfaction questionnaire.

RESULTS

In this study, 62 residents were randomized (32 to the WhatsApp group and 30 to the control group) and 22 residents in each group answered the online final evaluation. We found a difference between the WhatsApp and control groups for SCTs (60% [SD 9%] vs 68% [SD 11%]; P=.006) but no difference for MCQs (18/30 [SD 4] vs 16/30 [SD 4]; P=.22). Concerning satisfaction, there was a better global satisfaction rate in the WhatsApp group than in the control group (8/10 [interquartile range 8-9] vs 8/10 [interquartile range 8-8]; P=.049).

CONCLUSIONS

Compared to traditional e-learning, the use of WhatsApp for teaching residents was associated with worse clinical reasoning despite better global appreciation. The use of WhatsApp probably contributes to the dispersion of attention linked to the use of the smartphone. The impact of smartphones on clinical reasoning should be studied further.

The impact of neurosurgical procedure on cognitive resources: Results of bypass training

Background:

Neurosurgeons are exposed to unavoidable distractions in their natural operating environment. Distractions can affect both the surgeon's concentration and the safety and duration of the surgery. Such distraction can be studied by applying a simultaneous cognitive task during a surgical procedure.

Methods:

We used a previously described cognitive task: a forward (DF) and backward digit (DB) repetition task to interfere with the surgeon's attention during a training bypass. A pilot study was performed to find suitable digit repetition lengths. For the main experiment, we used four-digit strings. The test task was alternated across two consecutive sutures (n = 153, 8 bypasses), followed by two consecutive control sutures without digit repetition. The duration and the number of correct answers for the digit repetition task were compared to a baseline digit repetition without simultaneous surgery.

Results:

During the bypass surgery, digit repetitions (especially DB) became slower (P < 0.0001). More errors were made during DB compared to DF only during simultaneous bypass (P < 0.0001). However, we found no effect of digit repetition tasks on individual suture times (P = 0.823).

Conclusions:

The ability to engage in simultaneous tasks while performing surgery is diminished. A surgeon with extensive training can withstand external distraction without an effect on performance; however, this is achieved by partially ignoring the simultaneous task. Our data support that during surgery other cognitive tasks should be avoided to ensure safety.